Ruptured aneurysm of the noncoronary sinus of valsalva.

Sinus of Valsalva aneurysm is a rare disorder. It is usually congenital, but other origins have been described. It may be asymptomatic, or it may present as angina or with symptoms of valvular insufficiency or outflow obstruction. Once ruptured, it often produces hemodynamic instability. Diagnosis should be pursued with transesophageal echocardiography or catheterization. A 50-year-old man was admitted with symptoms of congestive heart failure. His functional capacity had declined over 3 years, worsening over the last 3 weeks. His medical history was significant only for gunshot to the right hemithorax, at age 25. He was found to be in distress, with signs of heart failure, S3 and S4 gallop, and systolic and diastolic murmur at the right sternal border. Two-dimensional echocardiography revealed an ejection fraction of 0.25, dilated left and right atria, and a sinus of Valsalva aneurysm with an aortic-right atrial shunt. Left and right heart catheterization revealed metallic fragments in the anterior chest wall, normal coronary arteries, and a step-up in the oxygen saturation from the inferior vena cava to the pulmonary artery. Aortography revealed that the aneurysm had ruptured into the right atrium. Surgical repair was performed. Ruptured sinus of Valsalva aneurysm demands prompt diagnosis and treatment. Patients are often men, in the 3rd or 4th decade of life when rupture occurs. In our patient, the position of the bullet and its fragments, leaflet perforation, and lack of a predisposing infection suggest a causal association between the gunshot wound and the aneurysm.